The job description for this position requires the medical professional to undertake administrative capacities. Working in hospitals, clinics, nursing homes, and other medical facilities, these specialists will carry out various tasks. Some of the typical duties listed on the Clinical Documentation Improvement Specialist Resume are – managing the creation of clinical files, maintaining a detailed record of each and every patient’s medical record, collecting information about the patient’s diagnosis and storing it in the system database, assessing accuracy of every document, tracking information about the patient’s diseases, educating medical coders about standard procedures and performing all other admin tasks as delegated.
To shine in this career line, candidates are expected to depict these skills in the resume – excellent communication skills, the ability to maintain accurate medical records, a thorough understanding of medical documentation and coding system; and being well-versed in using a variety of computer software. The education requirements vary based on employer preference, but they often require a Bachelor’s or Associate’s degree in health information technology, applied science, or health informatics.
Headline : International Physician with years of experience in the Health Industry. Background in General Practitioner, Bio ethicist, Professor and Clinical Documentation Improvement.
Skills : Electronic Medical Record, Clintegrity 360, CDR2.
Description :
Identified all procedures and secondary diagnoses for comorbidities/complications and documents.
Identified documentation issues such as quality, appropriateness, completeness, and reimbursement issues and communicate these issues.
Queried the medical staff and other providers as necessary via written/verbal communication.
Ensured the timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record.
Educated physicians, clinicians, and other CDIS staff and coders regarding the necessity of providing complete and clear documentation.
Assessed the skill level and competency of CDI staff by reviewing Working DRG versus final billed DRG.
Identified query opportunities missed by CDI staff, to obtain accurate and complete physician documentation.
Experience
5-7 Years
Level
Executive
Education
Certification
Clinical Documentation Improvement Specialist II Resume
Headline : A certified Clinical Documentation Improvement Specialist (CDIS) with over three years of active acute-care in-patients experience, a Physician with over eight years of clinical practice, an ICD-10 trained.
Skills : Technical Skills, Fluent in English.
Description :
Prepared & coordinated CDS led Bi-weekly meetings for ICD-10 Physician Education.
Able to discern the value of collecting marginal data against the potential administrative burden of obtaining additional specificity.
Initiated clinically relevant queries to physicians when documentation requires further specificity to accurately reflect the patients.
Worked knowledge of 3M 360 Encoder, ICD-10 & Third-Party Payers respective reimbursement systems.
Conducted follow-up reviews to support & assign a working or final DRG to be assigned upon patient discharge.
Worked as part of a team that had a projected income revenue goal. Working together we were able to double that goal, with a quarterly earning of dollars.
Reviewed medical records, identify missing or unclear information, and then act as a point of contact with the Physician to fulfill the record deficit.
Headline : Currently working as a traveling Clinical Documentation Improvement Specialist. Proficient experience working in multiple EHR, Coding & Reimbursement systems to include Epic, Meditech, 3M360 Encompass.
Skills : Medical Software Systems, Hard Working.
Description :
Accountable for improved the overall quality and completeness of clinical documentation at each facility.
Facilitated and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness.
Exhibited expert knowledge of clinical documentation requirements, DRG assignment, and clinical diagnoses & procedures.
Created and provided education for members of the patient care team regarding documentation guidelines.
Completed the initial review of patient records within 24-48 hours of admission.
Evaluated documentation to assign the principal diagnoses, pertinent secondary diagnoses, and procedures for accurate DRG assignment.
Information is incomplete or missed then provides appropriate communication with assigned providers.
Experience
5-7 Years
Level
Executive
Education
Nursing
Clinical Documentation Improvement Specialist I Resume
Objective : Registered Nurse with over fifteen years of experience in clinical / critical care nursing, as well as utilization management, case management and clinical documentation improvement.
Skills : Critical thinker, Excellent interpersonal, Team player.
Description :
Responsible for detailed clinical review of patient records including coding principal diagnosis, comorbid conditions, and procedures.
Ensured the quality and completeness of clinical documentation through physician queries.
Facilitated complete, accurate, and specific documentation of diagnosis and level of services provided which is utilized for appropriate coding.
Utilized software to collect, track, and report outcomes.
Participated in the analysis and trending of statistical data to identify opportunities for improvement.
Assisted with the preparation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
Educated physicians and other members of the patient care team regarding specific documentation needs, reporting, and reimbursement issues.
Headline : Process of transitioning from current residence in Connecticut to new home in Upstate. Seeking to obtain a Nursing position in that geographic region, which builds on and /or broadens.
Skills : OR Circulator, Scrubbing; Med-Surg Nursing.
Description :
Utilized Nursing knowledge and clinical experience, reviewed patient medical records for accuracy and specificity of clinical documentation.
Accessed and reviewed patient information via electronic data management systems for additional pertinent information.
Communicated with physicians via a query process to improve the quality of documentation within the patient record.
Maintained a computerized data form to track workflow and outcomes.
Worked together with clinical coding staff to ensure the most accurate reporting/billing of patient accounts.
Gathered data for quality improvement in the Clinical Documentation Specialist, CDI process.
Identified variances from practice and policy and participate in the education of physician staff.
Headline : To secure a position as a Clinical Documentation Improvement Specialist where will apply skills, knowledge and leadership qualities in providing the most accurate and complete medical records for coding.
Skills : Microsoft Office, Technical Skills.
Description :
Reviewed medical records concurrently for documentation improvement opportunities.
Worked closely with physicians and case managers to educate on proper documentation.
Improved documentation and capture CC and MCC's.
Improved case mix index and maximize hospital revenue.
Coded inpatient including heart and back procedures, same-day surgery accounts, ER records, outpatient accounts, skilled nursing facility accounts.
Award is given for going above and beyond expected duties.
Increased hospital revenue in six months and improving hospital case mix index.
Headline : Experience as a Clinical Documentation Improvement Specialist. Areas of expertise include ICU, CCU, Trauma 1, Surgery, Medical. Create and lead in the maintenance of a compliant query process.
Skills : Med-Surg Nursing, MS-Excel.
Description :
Assigned correct DRG/ICD-9 code and principal diagnosis extracted from clinical data.
Utilized 3M-HDM software encoder, data input, and to generate monthly reconciliation.
Created queries to physicians to clarify and specify needed documentation for correct reimbursement from Medicare and Blue Cross/Blue Shield.
Created letters for first-level appeals to Medicare and Blue Cross/Blue Shield.
Accessed Paragon EMR software for current clinical data information and HPF software for retrospective patient record information.
Achieved increased hospital reimbursements above the projected goal.
Ensured complete and accurate documentation is provided before discharge.
Experience
5-7 Years
Level
Executive
Education
Nursing
Lead Clinical Documentation Improvement Specialist Resume
Summary : A position of responsibility that allows for growth and advancement; utilizing technical, creative, and interpersonal knowledge and skill.
Objective : Seeking a full time position in the healthcare field where can contribute knowledge and skills as a clinical documentation improvement specialist to successfully help the Organization achieve their goals.
Headline : Highly competent Certified Clinical Documentation Improvement Specialist and Foreign Medical Graduate with extensive background in facilitation of physician documentation for patient conditions.
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